By Molly Mulebriar
How many times has an employer said to you “Yes, we ARE having issues with our TPA, but changing to another one is too disruptive and challenging. Plus, we are out of time since our renewal is just around the corner. We are just going to stay put for now and live with it.”
We call this the “Grin & Bare it” strategy towards managing health care.
Of course we know there is no such thing as a perfect TPA. However, some are better than others in more ways than one, including shared philosophies. (Selecting a Third Party Administrator)
You don’t hear any angst when changing PBM’s, or stop loss insurance. You don’t hear it when you change any other plan vendor such as audit firms, patient advocacy support services, large case management vendors, etc. So why the noise and angst about changing TPA’s?
The answer is pretty simple. We’ve all been conditioned to engage TPA services on a fronting basis rather than what they are truly are – clerks in the basement adjudicating (mostly automated) claims and performing other record keeping functions while tending to those pesky but automated voice message systems to be answered between coffee breaks and only if one is feeling well enough and its not too close to quitting time. (Hey Julie, lets sneak out early for a Banana Daiquiri at Happy Hour!”)
The truth is an employer who self-funds their health plan becomes the insurance company, not the TPA. Instead of printing I.D. cards complete with the TPA’s name and logo a plan should simply identify members as being covered by “ABC Fence Company Health & Welfare Plan” or “ABC Fence Company Group Health Plan.” Gone are all logos, including PBM, TPA, Network, etc.
Medical providers don’t care what an I.D. card looks like. They don’t care if it has a Blue Cross, United HealthCare or any other household brand name and logo on it. All they care about is (1) is the member eligible for coverage and (2) what’s the patient’s responsibility for the current encounter. Neither can be determined by looking at a typical I.D. card unless you’re clairvoyant. Most hourly intake clerks are not clairvoyant. In fact none are. And few, if any, have Crystal Ball experience.
So what happens when a member presents their “proof of insurance.” In the case of being pulled over by Officer Friendly as you’re traveling lickety-split to your doctors appointment, you can rest assured he’s calling in to verify insurance coverage before he issues his final diagnosis. This is no different than Clerk Friendly (no relationship to Officer Friendly) at the doctor’s office. Clerk Friendly picks up the phone and makes a call to a number printed on the card to verify eligibility and benefits while you patiently wait for an often extended time past your scheduled appointment in a germ ridden waiting room of equally frustrated yet-to-be-verified patients. Blue Cross, United HealthCare and other brand name health care members in the room get no faster service than those insured by Bumble Bee TPA.
Yet plan members are attached psychologically to identity insurance. When asked who their insurance coverage is with they may proudly say “I have Blue Cross” or they may whisper sheepishly “I have Bumble Bee TPA.”
Instead, the mindset should be based on truth. “I’m insured by ABC Fence Company Insurance.” Call the number on the card to verify benefits and eligibility please.” So Friendly Clerk does just that because she was going to do that anyway, her job depends on it.
The call is answered with “Good Morning! ABC Fence Company Health & Welfare Plan. How may I help you today!!!!” Depending on the nature of the call, the operator transfers the call to the appropriate department which could be in the cellar downstairs (TPA). Or if the call is for another matter such as patient advocacy support handled by another vendor other than the TPA, a warm call transfer is made to that vendor in any number of locations across the Fruited Plain.
All calls are answered the same way – “Good Morning! ABC Fence Company Health & Welfare Plan. This is claim services (or the patient advocacy department, or PBM, etc.), How may I help you this morning!!!!!!”
When a program is structured like this, changing plan subcontractors is not disruptive in the eyes of plan members and should certainly not be disruptive to any large degree to the plan sponsor. Nothing changes as far as anyone can see.
It’s no different than taking your car down to the mechanic and installing a new engine – the old one was having “issues” and you needed a change. So although a change was made (you changed motors) nothing really changed at all because you continue to drive the same car.
Molly Mulebriar is an investigative reporterette and infrequent contributor to this blog. She resides in Waring, Texas.
